High School Club Registration 2024-2025

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This registers your student to be involved in all My Life Matters High School clubs for the 2024-2025 school year.

Permission is for June 1, 2024 to May 31, 2025.

Students Name (first) *

Students Name (last) *

Gender? *

Male

Female

Grade *

9th

10th

11th

12th

Small Group (Staff Use Only)

Option 1

Clear selection

What School does the Student attend? *

Person

RCS

RCA

Homeschool

LCA

Other:

Student Birthdate *

YYYY

Students Age *

Mailing Address *

City, State & Zip Code *

Roxboro, NC 27573

Roxboro, NC 27574

Timberlake, NC 27583

Rougemont, NC 27572

Semora, NC 27343

Leasburg, NC 27291

Other:

Student Phone Number *

Student Contact Email *

Parent/Guardian Name *

Parent/Guardian Phone number (no spaces or hyphens) *

Parent/Guardian Email *

#1 Emergency contact name and number *

#2 Emergency contact name and number *

Allergies and Medication (list N/A if none) *

Church (if applicable)

We offer a shuttle from PECIL, RCA, RCS, and PHS to The Warehouse for club on Thursday afternoon. Seats are limited to first come first serve. Signing up for the shuttle does not guarantee a spot-parents/guardians must confirm with staff via text (Will Bailey 434-942-8894 Jordan Pickrel 434-251-4300) that the student may ride the shuttle prior to attending the first time. Once a shuttle seat is confirmed, you do not have to do anything else. *Please do not contact the school regarding the shuttle, always contact us directly.
*

Yes, my student can ride the PHS shuttle

Yes, my student can ride the RCS shuttle

Yes, my student can ride the PECIL shuttle

No, my student can not ride the shuttle

My student does not need the shuttle

Clear form

Never submit passwords through Google Forms.

This form was created inside of My Life Matters.

Does this form look suspicious? Report

Forms